Evergreen Psychological Services, LLC

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

20042335A Issued in IN

Legal business name

EVERGREEN PSYCHOLOGICAL SERVICES, LLC

Practice address

1155 Parkway Dr. Ste 200
Zionsville, IN 46077-8541

Phone

(317) 520-4650

NPI assigned

Jan 6, 2017

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Randall A. Young, MA, LMHC, LICDC, MAC

Title

Vice President/Business Administrat

Phone

(317) 520-4650

Specialties & licenses 2

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1483660800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1491868800000",
    "number": "1639615206",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1155 PARKWAY DR. STE 200",
            "city": "ZIONSVILLE",
            "state": "IN",
            "postal_code": "460778541",
            "telephone_number": "317-520-4650"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1155 PARKWAY DR. STE 200",
            "city": "ZIONSVILLE",
            "state": "IN",
            "postal_code": "460778541",
            "telephone_number": "317-520-4650"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EVERGREEN PSYCHOLOGICAL SERVICES, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-01-06",
        "last_updated": "2017-04-11",
        "status": "A",
        "authorized_official_last_name": "YOUNG",
        "authorized_official_first_name": "RANDALL",
        "authorized_official_middle_name": "A.",
        "authorized_official_title_or_position": "VICE PRESIDENT/BUSINESS ADMINISTRAT",
        "authorized_official_telephone_number": "317-520-4650",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MA, LMHC, LICDC, MAC"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": "IN",
            "license": "39001948A",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": "IN",
            "license": "20042335A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "201002540",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Clinical Psychologist in Zionsville, IN
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• Clinical Psychologist in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 11, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.